06 Flat foot impairs physical activity in children with juvenile idiopathic arthritis

Abstract Background Children with juvenile idiopathic arthritis (JIA) are less active compared with the general population due to pain and deformities, mainly of the lower limbs. Indeed, only 23% of children with JIA meet the public health recommendations of one h of moderate to vigorous physical activity daily [1]. In this context, foot involvement in JIA is a considerable limiting cause of physical activity. Objectives Our study aimed to investigate the types of static foot disorders that impede physical activity in children with JIA. Methods We conducted a cross-sectional study of patients with JIA according to the revised ILAR criteria. Socio-demographic and disease-related data were recorded. All patients underwent podoscope examination for varus or valgus deformity of the hindfoot and plantar footprint abnormality (flat foot or hollow foot). Patients with ankle or foot involvement due to congenital malformation or any other cause besides JIA were excluded. The impact of foot involvement on physical activity was assessed by the Oxford ankle foot questionnaire for children (OxAFQ-C). A higher score represents better functioning. We looked for the effect of foot abnormalities and their impact on physical activity. Results A total of 23 patients were collected. The mean age was 12.7 ± 3 [6–18] years and the mean age at diagnosis was 9.3 ± 3 [3–16] years. There was a female predominance with a sex ratio of 0.42. The majority of patients had secondary education (52%). The distribution of the different subtypes was dominated by the oligoarticular form (30%) and the enthesitis-related arthritis form (26%), followed by the polyarticular FR + (n = 1), polyarticular FR- (n = 3), psoriatic arthritis (n = 3), systemic (n = 1) and undifferentiated (n = 1) forms. The mean physical activity score assessed by the Oxford score was 73.52 ± 35.8 [0 – 100]. Plantar footprint abnormalities of the hollow and flat foot were found in 39% and 30% of cases respectively. These abnormalities were unilateral and bilateral in 7 and 9 patients respectively. Eleven patients (48%) had a hindfoot abnormality and 30% of them had a limitation of joint movement range. There was no statistically significant association between the physical domain of the Oxford score and the presence of a limited range of the talocrural joint (p> 0.05). A significant reduction in physical activity was associated with hindfoot pain (5.37 vs 89.56; p< 0.001) but was not associated with the presence of hindfoot abnormalities (p = 0.05). The presence of flat feet was significantly associated with impairment in all domains of the Oxford score, particularly in the physical domain (36.79 for the flat foot group vs 89.2 for the group without flat feet, p = 0.001). However, the presence of a hollow foot did not lead to an alteration of the physical activity of JIA patients (p> 0.05). Conclusion Our study showed that the flat foot was associated with a reduction in physical activity. Early detection of this abnormality and adapted podiatric care could improve the function of young patients with JIA. References [1] Gueddari S, Amine B, Rostom S, et al. Physical activity, functional ability, and disease activity in children and adolescents with juvenile idiopathic arthritis. Clin Rheumatol. 2014; 33(9):1289–1294. The implication to policy, practice, research and advocacy It is important to ensure that children with juvenile idiopathic arthritis are receiving appr


Background
Foot involvement in juvenile idiopathic arthritis (JIA) is common and affects about 60% of children [1]. Often overlooked by patients and practitioners, ankle and foot disability has been poorly studied and there are no accepted clinical practice guidelines for the diagnostic approach, as well as for the therapeutic management.

Objectives
Our study aimed to evaluate the effect of medical treatments on functional disability related to foot involvement in JIA.

Methods
We conducted a cross-sectional study including patients with JIA according to the revised ILAR criteria, collected from the rheumatology department of the Kassab National Institute. Sociodemographic and disease data (activity assessed by the Juvenile Arthritis Disease Activity Score 10 (JADAS-10) and therapeutic modalities) were recorded. Ankle and foot involvement were investigated by questioning and physical examination. We used the Oxford ankle foot questionnaire for children (OxAFQ-C); a validated, simple and reproducible score to assess the impact on the quality of life of children with foot problems [2]. This questionnaire encompasses 14 items corresponding to three dimensions: physical, school and play, and emotional. Higher scores represent better functioning. We searched for an association between the different drug treatments for JIA and the OxAFQ-C score.

Results
The study included 23 patients. The mean age was 13 AE 4 [6-18] years. The sex ratio was 0.42 with a female predominance. The age of the disease was 49 AE 40 months [6-180 months]. The distribution of the different forms of JIA was as follows: oligoarticular (n ¼ 7), enthesitisrelated arthritis (n ¼ 6), polyarticular FR þ (n ¼ 1), polyarticular FR-(n ¼ 3), psoriatic arthritis (n ¼ 3), systemic (n ¼ 1) and undifferentiated (n ¼ 1). Pain on walking and limitation of the talocrural joint was found in 39% and 30% respectively. The mean JADAS-10 score was 6.72 AE 6.1 [0-20]. Ten patients had high activity. Eighteen patients (78%) were taking level I analgesics and 14 patients (61%) were on non-steroidal anti-inflammatory drugs, 12 of them on demand. Naproxen was the most commonly used drug, followed by diclofenac. Eleven patients (48%) were on a disease-modifying anti-rheumatic drug (csDMARD). Methotrexate (MTX) was prescribed in 30% of cases with a mean dose of 7.91 mg/week [7.5-10]. Only one patient was on sulfasalazine. Four patients (17%) were treated with biologics: Etanercept (n ¼ 3) and Tocilizumab (n ¼ 1). The mean scores of the different domains of (OxAFQ-C) were as follows: 73.52 AE 35.89  in the physical domain, 84.2 AE 30 [6.25-100] in the school and play domain, in the emotional domain. There was no statistically significant association between the different domains of the Oxford score and the use of analgesics or NSAIDs (p> 0.05). Similarly, there was no statistically significant association between the different domains of the Oxford score and treatment with biotherapy (p> 0.05). However, patients on MTX had less functional impairment of the feet with a significant improvement in the physical domain (99.26 on MTX vs 62.5 without MTX, p ¼ 0.02, r ¼ 0.6).

Conclusion
Our work showed that only methotrexate was associated with an improvement in functional foot outcomes in JIA. Further studies are needed to highlight the effect of other therapies, especially biologics.

Background
Children with juvenile idiopathic arthritis (JIA) are less active compared with the general population due to pain and deformities, mainly of the lower limbs. Indeed, only 23% of children with JIA meet the public health recommendations of one h of moderate to vigorous physical activity daily [1]. In this context, foot involvement in JIA is a considerable limiting cause of physical activity.

Objectives
Our study aimed to investigate the types of static foot disorders that impede physical activity in children with JIA.

Methods
We conducted a cross-sectional study of patients with JIA according to the revised ILAR criteria. Socio-demographic and disease-related data were recorded. All patients underwent podoscope examination for varus or valgus deformity of the hindfoot and plantar footprint abnormality (flat foot or hollow foot). Patients with ankle or foot involvement due to congenital malformation or any other cause besides JIA were excluded. The impact of foot involvement on physical activity was assessed by the Oxford ankle foot questionnaire for children (OxAFQ-C). A higher score represents better functioning. We looked for the effect of foot abnormalities and their impact on physical activity. Results A total of 23 patients were collected. The mean age was 12.7 AE 3 [6-18] years and the mean age at diagnosis was 9.3 AE 3 [3-16] years. There was a female predominance with a sex ratio of 0.42. The majority of patients had secondary education (52%). The distribution of the different subtypes was dominated by the oligoarticular form (30%) and the enthesitis-related arthritis form (26%), followed by the polyarticular FR þ (n ¼ 1), polyarticular FR-(n ¼ 3), psoriatic arthritis (n ¼ 3), systemic (n ¼ 1) and undifferentiated (n ¼ 1) forms. The mean physical activity score assessed by the Oxford score was 73.52 AE 35.8 [0 -100]. Plantar footprint abnormalities of the hollow and flat foot were found in 39% and 30% of cases respectively. These abnormalities were unilateral and bilateral in 7 and 9 patients respectively. Eleven patients (48%) had a hindfoot abnormality and 30% of them had a limitation of joint movement range. There was no statistically significant association between the physical domain of the Oxford score and the presence of a limited range of the talocrural joint (p> 0.05). A significant reduction in physical activity was associated with hindfoot pain (5.37 vs 89.56; p< 0.001) but was not associated with the presence of hindfoot abnormalities (p ¼ 0.05). The presence of flat feet was significantly associated with impairment in all domains of the Oxford score, particularly in the physical domain (36.79 for the flat foot group vs 89.2 for the group without flat feet, p ¼ 0.001). However, the presence of a hollow foot did not lead to an alteration of the physical activity of JIA patients (p> 0.05).

Conclusion
Our study showed that the flat foot was associated with a reduction in physical activity. Early detection of this abnormality and adapted podiatric care could improve the function of young patients with JIA. Background Juvenile idiopathic arthritis (JIA) is one of the commonest rheumatic diseases in children. Hip involvement is a common problem in JIA patients and is associated with functional disability and poor outcomes. Intensive therapy is required to avoid joint replacement surgery. Little studied in the literature, the predictors of hip involvement are still unknown.

Objectives
Our study aims to identify the clinical, biological characteristic of patients with hip involvement and determine the associated risk factors. Methods A cross-sectional study including children with JIA according to the International League of Associations for Rheumatology (ILAR). The recorded data included sociodemographic features, disease characteristics (subtype disease, duration, and juvenile arthritis disease activity score (JADAS)) as well as treatment modalities. Regarding coxitis, we collected radiographs, ultrasound (US), and magnetic resonance imaging (MRI) of the hip when performed. Coxitis was defined by clinical (limited range of motion) and/or radiographic findings (destruction, synovitis, bone marrow oedema).

Conclusion
Our study shows that long disease duration exposes to a higher risk of hip involvement in children with JIA. Active disease and biological inflammatory syndrome could be associated risk factors. Studies with larger sample sizes are needed to draw definite causal associations.

Background
Juvenile idiopathic arthritis (JIA) is a group of inflammatory joint diseases that begin before the age of 16. Depending on the clinical form of JIA, medical treatment may involve long-term high-dose corticosteroid therapy, which may lead to aseptic femoral head osteonecrosis of patients. We report three observations of aseptic osteonecrosis of the femoral head in patients followed for JIA. 1st observation: Mr I.A, aged 19 years, presented with ankylosing spondylitis with peripheral involvement, with a juvenile onset, for which he had received a high dose of corticosteroids at an average of 1.5 mg/ kg/day since the age of 15 months on an intermittent basis. Clinically, the patient had a height of 1.65, a right limp when walking and limited movement of the right hip with a Lequesne algofunctional index of 10.5 (significant disability). MRI of the pelvis showed aseptic osteonecrosis of the right femoral head (ONATF), Arlet and Ficat stage 3. Observation 2: Mr A.B, 27-year-old, had systemic JIA since the age of 12. He received corticosteroid therapy at an average dose of 1 mg/kg/ day intermittently. Clinically the patient presents with signs of cortisone impregnation (a cushingoid face, purple stretch marks, thin skin) and bilateral cataract. The patient walks with the help of a crutch. The examination of the hips revealed a limitation of mobility of the left hip with a Lequesne algo-functional index of 18.5. Bone densitometry showed a decrease in bone density. Standard radiographs noted a left ONATF, Arlet and Ficat stage 4 with L4 and L5 vertebral fractures. 3rd Observation: Mr B.M, 26-year-old, followed for systemic JIA since the age of 14. He was treated with high dose corticosteroids at a rate of 1 mg/kg/day. The clinical examination revealed unevenness of the lower limbs, a left limp when walking, limited internal rotation and abduction of the right hip. The patient also had multiple inflammatory acne lesions and a bilateral cataract. Bone densitometry showed a decrease in bone density. Standard radiography showed bilateral ONATF, stage 3 on the right and 4 on the left according to Arlet and Ficat's classification, which required the placement of a double total hip replacement.

Conclusion
Corticosteroid therapy is one of the main risk factors for non-traumatic aseptic osteonecrosis. Our three patients presented with ONAT with major disability following long-term corticosteroid therapy. The efficacy of corticosteroids is well established but they should be used with caution to avoid side effects

Background
The pediatric Gait, Arms, Legs, and Spine (pGALS) is a practical quick musculoskeletal assessment to increase awareness of the joint disease, facilitate early recognition of joint problems, and prompt referral to specialist teams to optimize clinical outcomes. pGALS has been shown to be practical and useful, with excellent acceptability by children and their parents. Its use was limited in French-speaking countries because of the lack of the francophone version.

Objectives
To describe the steps of the translation of the pGALS francophone version using the Delphi approach. Methods Delphi method is the consensus-building method, providing the consensual opinion of the experts. For each translated item of the pGALS, the experts assessed the relevance using a scale ranging from 1 to 9 (not relevant-completely relevant). Then median was calculated giving for each item the position of the group: disagree (if the median < 3), equivocal (median between 4-6) and agreement (median >7). The degree of the convergence with the group was assessed to clarify this result: the group's opinion is consensual if 70% of the responses were within the range of the median; otherwise, it's ''not consensual''. For the no consensual and no relevant item, the experts propose a comment to reformulate the sentence.

Results
Three native speakers were invited to translate the English form of the pGALS into the francophone language. The different propositions were mixed in a consensual way by a children's musculoskeletal specialist. The version was validated according to the Delphi method. Six experts (pediatricians and rheumatologists) from different French-speaking countries were interviewed during 3 rounds by electronic survey